IDL 64-RIB (Page 1of 2)



IDL-64 RIB (Corporation or Partnership)(Page 1 of 2)COMMONWEALTH OF PENNSYLVANIA INSURANCE DEPARTMENTReinsurance Intermediary Broker License Corporation or Partnership ApplicationType or Print - Complete All Necessary InformationPART I – IDENTIFICATIONNOTE: A license is required for each unique Employer Identification Number.Employer Identification Number: FORMTEXT ??- FORMTEXT ?????Entity Type: FORMCHECKBOX Corporation FORMCHECKBOX PartnershipIncorporation/Formation Date: (mm/dd/yy) FORMTEXT ?????Full Legal Name of Applicant: FORMTEXT ?????Primary Address: FORMCHECKBOX Address to be used as mailing address FORMTEXT ?????Street (Required)(If applicable, include P.O. Box) FORMTEXT ????? FORMTEXT ?? FORMTEXT ?????CityStateZip CodeSecondary Address: FORMCHECKBOX Address to be used as mailing address FORMTEXT ?????Street (Required)(If applicable, include P.O. Box) FORMTEXT ????? FORMTEXT ?? FORMTEXT ?????CityStateZip CodeBusiness Telephone Number: ( FORMTEXT ???) FORMTEXT ??? - FORMTEXT ????Business Fax Number:( FORMTEXT ???) FORMTEXT ??? - FORMTEXT ????Business Email Address: FORMTEXT ?????PART II – LICENSED OFFICERS OR EMPLOYEESINSTRUCTIONS:Attach a listing of all officers or employees who will be acting as a reinsurance intermediary broker on behalf of the corporation or partnership.A biographical affidavit (NAIC format) and an IDL-63 RIB form must be completed and submitted by all officers and each employee who will be acting as a reinsurance intermediary broker on behalf of the corporation or partnership. PART III – REQUIREMENTSThe following requirements must be satisfied to qualify for a reinsurance intermediary broker license:Submit a notarized statement from the applicant stating intent to comply with the applicable statutes (40 P.S. §§ 321.3 and 321.4).Provide state of incorporation: FORMTEXT ??.Provide an organizational chart showing relationship with all affiliates.Provide a copy of the articles of incorporation or partnership agreement.PART IV – TRADING AS NAMEIf the applicant transacts business in Pennsylvania under an assumed trade name, provide the full name in the space provided below. NOTE: A corporation or partnership with its own Employer Identification Number cannot be used as a trading as name. Corporation or partnership applicants must have trading as names registered with the Pennsylvania Department of State.Trading as Name: FORMTEXT ?????IDL 64-RIB (Corporation or Partnership) (Page 2 of 2)Employer Identification Number: FORMTEXT ??- FORMTEXT ?????PART V – BACKGROUND INFORMATIONYESNO FORMCHECKBOX FORMCHECKBOX 1. HAS THE APPLICANT EVER BEEN PENALIZED OR FINED OR HAD A LICENSE REFUSED, SUSPENDED, OR REVOKED BY THIS DEPARTMENT OR THE INSURANCE DEPARTMENT OF ANY OTHER STATE OR PROVINCE OF CANADA OR IS ANY SUCH ACTION NOW PENDING?(If yes, provide a full explanation on a separate sheet of paper.) FORMCHECKBOX FORMCHECKBOX 2.HAS THE APPLICANT EVER BEEN CONVICTED OF OR PLED NOLO CONTENDERE (NO CONTEST) TO ANY MISDEMEANOR OR FELONY OR CURRENTLY HAVE PENDING MISDEMEANOR OR FELONY CHARGES FILED AGAINST YOU? (MISDEMEANOR DOES NOT INCLUDE MINOR TRAFFIC VIOLATIONS.)(If yes, give date, name, and address of court, basis, and outcome.) FORMCHECKBOX FORMCHECKBOX 3.IS THE APPLICANT FAMILIAR WITH ARTICLES VII OF THE INSURANCE DEPARTMENT ACT OF MAY 17, 1921, P.L. 289. NO. 285 (40 P.S. § 321.1 ET SEQ.) THAT GOVERNS REINSURANCE INTERMEDIARYBROKERS? FORMCHECKBOX FORMCHECKBOX 4.IS THERE ANY DISPUTE WITH THE APPLICANT’S ACCOUNTS WITH ANY COMPANY, AGENCY, OR INSURED? (If yes, attach a letter of explanation.) FORMCHECKBOX FORMCHECKBOX 5.DO ALL UNLICENSED OFFICERS, PARTNERS, OR EMPLOYEES UNDERSTAND THAT THEY CANNOT PERFORM ANY ACT OF A REINSURANCE INTERMEDIARY BROKER IN PENNSYLVANIA?Officers/PartnersList the following information for all officers of the corporation or partners of the partnership (licensed or unlicensed). FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NameSoc Sec # / EIN Title FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NameSoc Sec # / EINTitle FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NameSoc Sec # / EINTitle FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NameSoc Sec # / EINTitleATTACH A SEPARATE SHEET LISTING OTHER OFFICERS/PARTNERS IF NECESSARYPART VI – APPLICANT’S CERTIFICATIONI do hereby certify under penalty or perjury that the foregoing statements and information are true and correct and that any license issued in consequence hereof shall be contingent upon the truth of these statements. Furthermore, I confirm that I understand fully the insurance laws and regulations of Pennsylvania regarding reinsurance intermediary broker activities.NOTE: There are criminal penalties for false statement.Notary SealSubscribed and sworn before me on this__________day of ___________, 20____.Commission Expires:_________________________________________________Officer/Partner Signature FORMTEXT ?????_________________________________________________Officer/Partner Name (print or type) FORMTEXT ?????_________________________________________________Officer/Partner Title (print or type)Rev. 07/02/2015 ................
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